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Thomas Kozlowski, OD
Trans-Synaptic Degeneration in Multiple Sclerosis and the Evolving Role of OCT
I.
Case History
 Patient Demographics
o 33yo WF
 Chief Complaint
o Routine follow-up to monitor visual field loss secondary to Multiple
Sclerosis
 Ocular History
o Visual Field Defect secondary to Multiple Sclerosis
 No history of optic neuritis
o Dry Eye Syndrome
o Hyperopia
o (-)eye injuries or surgeries
 Ocular Medications
o Artificial Tears
 Medical History
o Multiple Sclerosis (Relapsing-Remitting)
 Diagnosed 01/30/13
 Brain MRI (01/30/13)
 Lumbar Puncture (02/01/13)
 h/o copaxone treatment, currently untreated (patient is hesitant and
unwilling to take medication)
o Asthma, Obesity, PTSD, Depression, Anxiety
 Medications
o Albuterol, flunisolide, citalopram, lorazepam, levothyroxine, multivitamin
II. Pertinent Findings (01/27/15)
 Visual acuity: 20/20 OD,OS (sc)
 Color Vision: Normal
 EOMs: S+F, (-)pain or diplopia
 Pupils: ERRL, (-)APD
 Additional Testing
o HVF 30-2
 01/30/13: Incomplete, incongruous (OS>OD) right hemianopia
 02/27/13: same as above, mild improvement
 09/26/13: same as above, mild improvement
 01/27/15: same as above, OD essentially resolved, OS mildly
improved
o Spectralis OCT: RNFL
 01/30/13: Global 99/103, no flags
 02/27/13: Global 96/103, no flags
 03/04/14: Global 83/87
 OD Flags: Temporal, BDL Global
 OS Flags: ST, IT, BDL Temporal
 Significant progression!
 01/27/15: Global 81/86 (same flags as previous)
 Overall stable
o Spectralis OCT: Posterior Pole Analysis
 Interpretation
 Total Thickness: 276 OD, 263 OS
 OD: thinning of inner retinal layers nasal to fovea respecting the
vertical midline
 OS: thinning of inner retinal layers temporal to fovea respecting the
vertical midline
 Impression: pattern of retinal thinning correlates with pattern and
severity of visual field
III. Differential Diagnosis
 Addressed in Discussion
IV. Diagnosis and Discussion
 Multiple Sclerosis
o Epidemiology
o Pathogenesis, disease course
o Diagnosis
 Role of MRI
o Symptoms
o Visual Sequelae
 Blurred vision, visual field defects, color vision desaturation
 Optic neuritis
 Role of OCT in the Management of MS Patients
o Retinal changes in MS
 Layer-specific atrophy
 RNFL, GCL, INL?
 Role of Peripapillary RNFL, Macular Volume scans
o A. Retinal Damage in MS with Optic Neuritis (MSON)
 Optic neuritis as presenting symptom in 15-20% of MS patients,
affects 50-70% throughout course of disease
 Pathogenesis
 Optic atrophy, pallor of optic nerve
 OCT Findings
 Loss of approximately 20 microns after ON
 20% loss in RNFL thickness
o B. Retinal Damage in MS with No Optic Neuritis (MSNON)
 Surprisingly, RNFL reduction has also been observed in eyes with MS
and no history of optic neuritis
 Mean reduction = 7-10 microns thinner than normal controls
 Mean RNFL decrease/year (microns) in MS patients vs.
normal
Differential Diagnosis
 1. Subclinical inflammation of optic nerve?
 2. Primary retinal pathology?
 3. Retrograde trans-synaptic degeneration of retinal
axons
 Visual pathway review
 Pathogenesis: optic radiation damage causing retinal
thinning
 Evidence in CVA patients
 MRI, OCT evidence
 HVF/OCT correlation in this patient as evidence of
trans-synaptic degeneration of nerve axons
secondary to MS
o Role of OCT in Managing MS Patients: Present and Future
 Relationship between OCT and brain atrophy
 Evidence exists to support the idea that retinal degeneration
measured by OCT reflects degree of neurologic
degeneration, suggesting OCT measurements may be useful
in measuring CNS damage and disease progression
 If RNFL thinning is indeed correlated with global brain atrophy and
disease progression, OCT may become an essential tool in the care of
these patients
 Noninvasive, inexpensive, objective, sensitive
 May lower threshold for initiation of treatment

V. Conclusions
 Evidence exists to support the theory of trans-synaptic degeneration of retinal
axons occurring in MS. This degeneration can be measured by OCT, and may be a
marker of overall disease progression.
 Currently, the role of OCT in managing MS patients is not clearly defined. It is now
complementary to MRI and general neurologic examination.
 As technology evolves and more clinical studies are completed, it is likely the role of
OCT will become more and more relevant in monitoring progression in patients
with MS, possibly even becoming standard of care.
o Evolving role of the OD in the management of MS patients
Bibliography
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